Healthcare Provider Details

I. General information

NPI: 1578890497
Provider Name (Legal Business Name): ZARA LITTLE WING LACKMAN D.C., D.I.C.C.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2009
Last Update Date: 11/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2003 ROBIN LN
WAUSAU WI
54401-7158
US

IV. Provider business mailing address

2003 ROBIN LN
WAUSAU WI
54401-7158
US

V. Phone/Fax

Practice location:
  • Phone: 715-845-3775
  • Fax: 715-848-9015
Mailing address:
  • Phone: 715-845-3775
  • Fax: 715-848-9015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3393-012
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code111NP0017X
TaxonomyPediatric Chiropractor
License Number3393-012
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: